Assessing Current Nephrology Fellows' Perceptions of Future Earnings as Attending Physicians

Nephrology is challenged by decreasing trainee interest and an aging workforce.¹ The perception of low compensation has been cited as a factor deterring trainees from pursuing nephrology.² Therefore, we surveyed current nephrology trainees' perceptions of their future compensation as attending physicians and whether educational debt affected fellows' choice to pursue nephrology.

Questions assessing fellows' perceptions of nephrology earnings and influence of educational debt were developed, validated, and included in the 2024 American Society of Nephrology (ASN) Nephrology Fellow Survey (https://github.com/ASNDataAnalytics/asn_2024_fellow_survey) disseminated from April 30 to May 22, 2024 (Johns Hopkins IRB00205206). Pre- and perifellowship perceptions of nephrology compensation were measured using a Likert scale (far above average, above average, average, below average, and far below average). Respondents could skip questions they preferred not to answer. Percentages were calculated using question-specific totals in the denominator (analyses performed using R).

The survey was disseminated to 962 adult, pediatric, and adult/pediatric fellows, of whom 447 participated (46% response). Most of the respondents were adult-only fellows (88%), international medical graduates (53%), US citizens (62%), and male (56%; Table 1).

Table 1.

Participant demographics and results^a

Variable	Adult Nephrology (n=393)	Pediatric Nephrology (n=45)	Adult/Pediatric Nephrology (n=9)
Medical school (N=447)
IMG	224 (57%)	12 (27%)	NRb
USMG	169 (43%)	33 (73%)	NRb
Adult nephrology fellowship type (n=393)
Clinical nephrology	352 (79%)	NAb	NAb
Research	16 (4%)	NAb	NAb
Interventional nephrology	3 (1%)	NAb	NAb
Nephrology-critical care medicine	19 (4%)	NAb	NAb
Home dialysis/dialysis	1 (0.25%)	NAb	NAb
Other	2 (0.5%)	NAb	NAb
Not provided	54 (12%)	NAb	NAb
Citizenship (N=447)
US Citizen	234 (60%)	34 (76%)	9 (100%)
Permanent resident	32 (8%)	2 (4%)	0 (0%)
H-1 visa	33 (8%)	2 (4%)	0 (0%)
J-1 visa	89 (23%)	4 (9%)	0 (0%)
Other visa	1 (0.25%)	2 (4%)	0 (0%)
Prefer not to answer	2 (0.5%)	0 (0%)	0 (0%)
Not provided	2 (0.5%)	1 (2%)	0 (0%)
Years of training completed (N=447)
1	190 (48%)	14 (31%)	2 (22%)
2	194 (49%)	13 (29%)	4 (44%)
3	7 (2%)	18 (40%)	2 (22%)
4 or more	2 (0.5%)	0 (0%)	1 (11%)
Sex (N=447)
Male	231 (59%)	16 (36%)	NRb
Female	156 (40%)	29 (64%)	NRb
Prefer not to answer	6 (2%)	0 (0%)	NRb
Ethnicity (N=447)
Hispanic/Latina/Latino	45 (12%)	7 (16%)	NRb
Prefer not to answer	13 (3%)	0 (0%)	NRb
Race (N=447)
American Indian or Alaska Native	3 (1%)	1 (2%)	NRb
Asian	179 (44%)	8 (18%)	NRb
Black	37 (9%)	3 (6%)	NRb
Pacific Islander	0 (0%)	0 (0%)	NRb
Prefer not to answer	39 (10%)	2 (4%)	NRb
White	139 (34%)	26 (55%)	NRb
Fellows' entering practice—first employer (n=133)
Private practice	67 (50%)	0 (0%)	0 (0%)
Academic hospital	43 (32%)	10 (83%)	1 (100%)
Nonacademic hospital	19 (14%)	2 (17%)	0 (0%)
Government	5 (4%)	0 (0%)	0 (0%)
Educational debt (n=281)
Median (interquartile range)	$199,000 ($313,250)	$246,000 ($275,000)	$333,000 ($93,750)
No. of fellows reporting debt	393	45	9
Influence of debt on pursuing nephrology (n=235)
Very influential	10 (3%)	1 (2%)	0 (0%)
Somewhat influential	35 (9%)	3 (7%)	1 (11%)
Slightly influential	54 (14%)	7 (16%)	2 (22%)
Not at all influential	76 (19%)	10 (22%)	5 (56%)
NA	27 (7%)	3 (7%)	0 (0%)
Fellows with debt: participation in debt forgiveness (n=236)
Yes	76 (38%)	20 (80%)	5 (63%)
No	127 (62%)	5 (20%)	3 (37%)
Type of loan forgiveness (n=110)
Public service loan forgiveness	72 (89%)	20 (83%)	5 (100%)
ASN's loan mitigation program	2 (3%)	3 (13%)	0 (0%)
State-based programs	5 (6%)	0 (0%)	0 (0%)
NIH loan repayment program	1 (1%)	1 (4%)	0 (0%)
Armed services loan replacement program	1 (1%)	0 (0%)	0 (0%)

ASN, American Society of Nephrology; IMG, international medical graduate; NA, not applicable; NIH, National Institutes of Health; NR, not reported; USMG, US medical graduate.

^aPercent totals may not sum to 100% because of rounding.

^bNot applicable because this measure was only relevant for, and exposed to, adult nephrology fellows. Not reported because of a low total number of responding adult/pediatric nephrology fellows.

A majority perceived nephrology compensation as far below average/below average compared with other specialties before and during fellowship (59% and 55%, respectively). However, 26% noted ≥1-level improvement on the five-point Likert scale in their perception between these two time points. Respondents did not reach consensus in assessing the importance of future earning potential in choosing nephrology: 29%, very/extremely important; 36%, not at all/slightly important; and 34%, neutral.

Of 281 respondents reporting debt, median debt was $209,000. US medical graduates (median $250,000, n=161) carried more than international medical graduates ($47,000, n=120) and women ($252,500, n=126), more than men ($169,500, n=152). Thirty-nine percent of respondents with debt indicated it was not at all influential in choosing nephrology (n=91; 39%). Less than half (43%) of the respondents with debt were enrolled in debt forgiveness programs and had higher median debt than those not enrolled ($301,000 versus $158,000). The Public Service Loan Forgiveness Program was the most reported loan forgiveness program (n=97, 88%).

Before fellowship, most of the respondents perceived nephrology compensation as below average. However, only 29% indicated compensation was very/extremely influential in choosing nephrology. This would suggest most of the respondents did not weigh this factor heavily when choosing nephrology. This is inconsistent with previous surveys of internal medicine residents.³ This has been observed in other nonprocedural internal medicine subspecialties, including infectious disease, where one study found that among those interested in infectious disease who did not apply, low perceived compensation was the main dissuading factor.⁴ Although perception of below-average compensation may not have been influential for those choosing nephrology, it will be important to explore whether this sentiment is shared among those who passed on nephrology for another specialty.

Data show nephrologists earn more than most hospitalists and certain subspecialists,⁵ yet trainees perceive nephrology compensation as below average. One way to combat this gap between perceived and actual compensation is to increase transparency around nephrology compensation and long-term earning potential, particularly early in training. Adequately defining nephrology compensation to include all revenue streams nephrologists can access is also important. A subset of respondents (26%) reported improved perception of future compensation during fellowship. This suggests that fellows broaden their comprehension during training, potentially from interacting with practicing nephrologists or from conferences, such as Nephrology Business Leadership University.⁶

Substantial medical school debt has been cited as a deterrent to pursuing nephrology.⁷ Although most of the respondents reported debt, the majority reported minimal/no influence on pursuing nephrology. Although this may be true for those who chose nephrology, high debt combined with perceived low compensation may have deterred those choosing another specialty.

Less than half with debt were enrolled in a loan forgiveness program, although 49% reported debt having some degree of influence on choosing nephrology. This suggests underutilization of existing loan forgiveness services. Understanding why fellows did not enroll in such programs may provide greater insight into barriers and improve access and enrollment. Because many loan forgiveness programs are stipulated by service commitment to health professional shortage areas, this can also improve patient access to nephrology specialist services. Similarly, promoting nephrology-specific loan forgiveness programs may make nephrology more attractive to those heavily influenced by debt.

Our study's limitations include a 46% response rate that could result in nonresponse bias. In addition, although we attempted to ensure question reliability, compensation can be interpreted subjectively. Differentiating between salary and long-term earning potential is necessary to increase transparency. Despite these, our study offers key insights into nephrology fellows' perceptions regarding compensation.

In conclusion, although perceptions of compensation may contribute to declining nephrology interest, compensation alone was not a primary factor for choosing nephrology for most current fellows responding to this survey. Future efforts need to explore how trainees in other specialties view nephrology compensation, and bridging the gap between perceived and real compensation may help with future recruitment. Furthermore, improving awareness of and access to loan forgiveness opportunities, particularly nephrology-specific ones, may help expand the nephrology workforce.

Supplementary Material

cjasn-20-0993-s001.pdf ^{(1.3MB, pdf)}

Disclosures

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/CJN/C152.

Funding

None.

Author Contributions

Conceptualization: Suzanne M. Boyle, Rasha Raslan, Jefferson L. Triozzi.

Data curation: Kurtis A. Pivert.

Formal analysis: Suzanne M. Boyle, Kurtis A. Pivert, Rasha Raslan, Jefferson L. Triozzi.

Investigation: Suzanne M. Boyle, Kurtis A. Pivert, Rasha Raslan, Jefferson L. Triozzi.

Methodology: Suzanne M. Boyle, Kurtis A. Pivert, Rasha Raslan, Jefferson L. Triozzi.

Project administration: Suzanne M. Boyle.

Resources: Suzanne M. Boyle, Kurtis A. Pivert.

Software: Kurtis A. Pivert.

Supervision: Suzanne M. Boyle.

Writing – original draft: Rasha Raslan.

Writing – review & editing: Suzanne M. Boyle, Kurtis A. Pivert, Jefferson L. Triozzi.

Data Sharing Statement

All data are included in the manuscript and/or supporting information. Data cannot be shared. The 2024 American Society of Nephrology Nephrology Fellow Survey is a human subjects research project (Johns Hopkins IRB00205206) and non-aggregated data are not available.